Clinical Social Work Theory and Practice Perspectives

A DEFINITION OF CLINICAL SOCIAL WORK PRACTICE

• Clinical social work practice applies theory and methods to the

resolution and prevention of psychosocial problems

experienced by individuals, families, and groups.

• Clinical social work is grounded in the values of the social

work profession

• Clinical social work promotes social and economic justice by

empowering clients who experience oppression or

vulnerability to problem situations.

A DEFINITION OF CLINICAL SOCIAL WORK PRACTICE (cont.)

• Clinical practice is based on an application of human development theories

within a psychosocial context

• Clinical practice focuses on issues of human diversity and multiculturalism

• The impact of social and political systems on the client is considered

• Clinical social work takes place in the context of a purposeful relationship

• Consciously using one’s professional self is central for building and

maintaining a productive therapeutic alliance

Range of Clinical Social Work Activities

• Ensuring Responsive Agencies/Organizations– Accessibility for clients (those with needs receiving services?)

• Clinical Interventions – Client engagement – Assessment– Planning – Intervention– Evaluation

• Environmental Interventions– Linkage:

• Includes mediation between agencies

Range of Clinical Social Work Activities (cont.)

Environmental Interventions (cont.)• Monitoring / Reassessment:

– Transitions between service settings – Information management

• Advocacy – Social action – Representation of client interests – Promotion of empowerment, self-determination

• Resource Development (including agency policy formulation)

• Outcome evaluation

Types of Theories

• Case theories: explain behavior of one client– What is your “theory” about the causes of client's behavior

• Mid-range theories: explain a set of behaviors– Explanation as to why unemployed males can demonstrate

domestic violence

• Grand theories: explain all sets of events and theories– Piaget’s theory of cognitive development

Definition of Practice Theory

• A coherent set of ideas about human nature, including concepts of :

– Health and illness

– Normalcy and deviance

– The nature of change

• Practice theory provides:

– verifiable or established explanations for behavior

– rationales for intervention.

Practice Theory Functions

• Simplifying complex phenomena into a focus on client’s thoughts, feelings and

behaviors

• Identifying our knowledge gaps about clinical situations

• Explaining and predicting client cognitions and behavior

• Bringing order to the selection of intervention targets and strategies

• Bolstering professional self-discipline by protecting against irrational procedures

• Promoting generalization among clients by cumulative practice knowledge

• Mobilizing social energy to coordinate the work of other service providers

• Enhancing our status within our agencies and among our peers

•

Benefits of Theory

Theory Focuses Attention

• When the social worker “knows” what to do, assessment and intervention

activities make better use of time and other therapeutic resources

• Commitment to a body of thought “greater than oneself” bolsters

professional self-discipline.

• In “naive eclecticism” our choices for intervention might emerge outside of

awareness and be influenced by irrational factors

Theory Protects the Client

• The worker can maintain a healthy distance from the client.

• Without a theoretical base, “clinical skepticism may be subverted in the

service of empathy”.

Challenges of Using Theory

• There is a potential harm of rigidly adhering to any

practice theory.

• Since theories simplify complex human behavior, they:

• Are reductionist

• Can be anti-humanistic

• Create self-fulfilling prophecies by biasing perceptions

of the client

• Blind us to alternative understandings of behavior.

THE RELATIONSHIP OF THEORY TO PRACTICE

Assumptions about Human Behavior

“Primary” Practice Theory (for Assessment)

Practice Models(Guiding strategies for working with certain types of clients)

Practice Strategies(For approaching a specific client)

Interventions(The implementation of practice strategies; what we actually do

to facilitate the change process)

Relationship Between Theory and Intervention Strategies

• Not every theory has unique intervention strategies

– i.e. relaxation exercises or mindfulness practices could be use by both a behaviorist as well as an ego psychologist

– Ego psychologist may see psychodynamics at root of addiction; but, use behavioral methods for changing self-destructive behavior

Theory and Practitioner’s “Practice Model”

• Practice model: guiding strategy for working with certain types of clients– i.e. Begin with behavioral techniques to extinguish

destructive and encourage constructive behavior– Then, undertake reflective interventions for insight

development (person-situation reflection)

• Practice model needs to individualized to client’s personal and environmental characteristics

Curative Factors in All Practice Interventions

• Perception of practitioner, by client, as competent and caring– Therapeutic alliance

• “Special setting” of seeking therapy promotes client’s sense of safety and expectation of help

• Practitioner is “congruent” with client’s perception of problem and world view– Practitioner’s ongoing attention too client’s frame of reference

• Client is given new opportunities for enhancing mastery

Curative Factors in Practice (cont.)

• Miller, Duncan and Hubble (2005):– Client characteristics associated with clinical

outcome (account for 40% of outcome):• Nature of the problem• Motivation• Participation

– Quality of therapeutic alliance (30%)– Guiding theory or model (15%)– Placebo effect (15%)

Curative Factors in Practice (cont.)

• Carkoff and Truax: Predictors to client retention in treatment:

– Empathy– Congruence– Genuineness

Practitioner’s Reasons for Theory Selection

• Research support• Belief that theory produces positive results (in

context of practitioner’s time and other resources)• Useful intervention techniques• Consistent with practitioner's values, knowledge,

skills and worldview• Habit• Use by agency or supervisor/s

Selecting a Theory for Practice

• A good theory for practice should be:– Coherent (internally consistent)– Useful– Comprehensive (applicable across a range of

clients)– Parsimonious (uncomplicated to use)– Testable

CLINICAL PRACTICE THEORIES

• Focus on Reflection: Psychodynamic Theories

• Ego Psychology (for individuals and groups)

• Object Relations (for individuals and groups)

• Self Psychology (Kohut)

• Family Emotional Systems (Bowen)

CLINICAL PRACTICE THEORIES (cont.)

• Focus on Conscious Thought / Observable Behavior

• Cognitive Theory (for individuals and groups)

• Behavioral Theory ((for individuals and groups)

• Interpersonal Therapy (a model)

• Structural Family Theory

CLINICAL PRACTICE THEORIES (cont.)

• “Newer” Theories and Models:– Solution –focused therapy– Motivational Interviewing– Narrative Theory

Characteristics of the Social Work Perspective (to be considered when selecting practice theory)

• Consistent with Social work Core values:– challenging social injustice – pursuing social change – Advocacy on behalf of the vulnerable and oppressed

• Strengths-oriented clinical practice– Affects the nomenclature (challenge, not problem)– Collaborative therapeutic alliance– Client as expert (standpoint theory)

• Risks and resilience framework– Bolster protective factors and reduce individual or environmental hazards– Resilience=mastery of tasks despite adversity

Characteristics of the Social Work Perspective (cont.)

• Applicable for multiculturalism– Commitment to work with diverse, underserved and marginalized populations– Cultural competence = knowledge, attitudes and skills

• Facilitative of Client Empowerment– Developing the capacity for receipt of rights, resources and opportunities– Levels of empowerment: Personal, interpersonal and structural – Assisting client to understand: “the personal is political”

• Supportive of Spirituality– Deriving a sense of meaning and purpose to one’s life

Client Empowerment as a Defining Characteristic

• Personal:– A positive sense of self-worth and competence– The ability to influence the course of one’s life

• Interpersonal:– Engagement within meaningful relationships– The capacity to work with others to control aspects of public life

• Structural/Political: – The ability to access resources, rights and opportunities– An ability to access the mechanisms of public decision-making

Limitations to Promoting Client Empowerment• Mutually agreed on roles between social worker and client for

responsibility and power– Some clients prefer the social worker to be the expert

• Social workers may themselves feel or be “disempowered” (lacking respect and influence) in the context of inter-professional work

• Empowerment as “enabling” problem behaviors (social workers may feel the need to take charge or be coercive in some situations)

• May draw attention away from the individual client onto larger-scale issues

Spirituality as a Defining Characteristic

• A sense of meaning, purpose, and connectedness to other “beings”

• Spirituality’s “nexus” is within impassioned ideas and action– “Where your energy is…spirit resides…”

• Categories of meaning may include:– belief systems– social and political concerns/action– creative pursuits– hope in defiance of suffering

Challenges to the Social Worker in Addressing the Client’s Spirituality

• Social worker’s self-understanding of her/his spiritual beliefs/worldview and its impact on practice

• Capacity to consider client functioning within a broad context of meaning (bringing consistency to the client’s present and ultimate concerns)– A spiritual or existential crisis at foot?

• Willingness to encourage client disclosure of spiritual concerns, when appropriate

• Ability to help clients identify meanings and purposes that can guide them in making growth-enhancing decisions– “Lemonade out of lemons…”